ISSN (0):2395-2822; ISSN (P):2395-2814

Clinical Profile of Acute Coronary Syndromes (ACS) in North Indian Population: A Prospective Tertiary Care Based Hospital Study.

Sandeep Sharma!, Aamir Rashid?, Mohammad Ashraf?, Mohd Ismail*, Masood Tanvir®, Pooja Sharma®, Shahood Ajaz’

1Post graduate Scholar, Department of Medicine, Government Medical College, Srinagar, Jammu and Kashmir, India,,

Senior Resident, Department of Cardiology SKIMS.

3Assistant professor, Department of Medicine, Government Medical College, Srinagar, Jammu and Kashmir, India,

4Associate Professor, Department of Medicine, Government Medical College, Srinagar, Jammu and Kashmir, India,

5Professor, Department of Medicine, Government Medical College, Srinagar, Jammu and Kashmir, India,

Senior Resident, Department of Obstetrics and Gynaecology, Government Medical College, Srinagar, Jammu and Kashmir, India, 7Post-graduate Scholar, Department of Medicine, Government Medical College, Srinagar, Jammu and Kashmir, India.

Received: July 2017 Accepted: July 2017

Copyright: © the author(s), publisher. It is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: The overall prevalence of coronary artery disease in Jammu &Kashmir population studied by all diagnostic measures is 7.54% with rural of 6.7% with urban population . Very scarce data is available regarding clinical profile of ACS patients in our Kashmiri population. Aim: To study the clinical profile, risk factors prevalence, angiographic profile in acute coronary syndrome (ACS) patients of North Indian population. Methods: The study was conducted at GMC, Srinagar, Jammu and Kashmir, India. It was prospective observational study. It included all patients, admitted as ACS in between the period from April 2014 to August 2015 with a diagnosis of acute coronary syndrome. All-cause 30 days mortality was seen in all patient taken under study. Results: In our study total of 693 ACS patients were enrolled. The mean age of patients was 60.72+ 12.02 years range (32-90 years). Males were 522 while as females were 171(M: F 4:1). Most patients had STEMI 430 (62.04%) followed by (NSTEMI) 227 (32.75%) and unstable angina (UA) 36 (5.19%). 308(44%) were diabetics while as 385(56%) were non-diabetics .Hypertension was present in 516 of 693 patients (74.45%). BMI > 25 was seen in 405 (58.44%) patients and 45 patients (6.5%) had BMI of more than 30.Smoking as a risk factor was present in 456 patients (65.80%). Past history of CAD was present in 87 (12.5%) of patients .Dyslipidemia was present in 415 (59.8%) patients. Angiography was done in 1443 (92.38%) patients. Left anterior descending was most commonly involved vessel (2/3rd cases) followed by near similar involvement of right coronary artery and left circumflex while as left main was least commonly involved. Single-vessel disease was present in 15 (41.6%) UA, 140 (61.67%) NSTEMI and 237 (55.11%) STEMI patients. Double-vessel disease was present in 10 (27.77%) UA, 47 (20.7%) NSTEMI and 86 (20%) STEMI patients. Triple vessel disease was present in 3 (8.3%) UA, 22 (9.6%) NSTEMI, 49 (11.39%) STEMI patients. LM disease was present in 1 (2.7%) UA, 3 (1.3%) NSTEMI, 4 (0.9%) STEMI patients. Complications; ventricular septal rupture occurred in 1 (0.1%), free wall rupture in 1 (0.1%), cardiogenic shock in 20 (2.8%), severe mitral regurgitation in 2 (0.28%), complete heart block in 5 (0.7%) patients. Total 50 (7.2%) patients died in hospital. Conclusion: STEMI was most common presentation. LAD was most commonly involved vessel .Males predominated in our ACS population. Hypertension and Smoking were most prevalent risk factors. . Diabetics had more aggressive disease with higher morbidity and mortality as compared to non-diabetics.

Keywords: Acute coronary syndrome non-ST elevation myocardial infarction, ST elevation myocardial infarction, unstable, angina, Kashmiri population.

INTRODUCTION

Coronary artery disease is leading cause of mortality worldwide and by 2020,"! will be first in the leading causes of disability.”!

The prevalence of CAD has increased from 1.1% to about 7.5% in the urban population and from 2.1% to 3.7% in the rural population in last three decades."! The overall prevalence of coronary artery disease in Jammu &Kashmir population studied by

Namia-& Addrads of Cartespondina Author all diagnostic measures was 7.54% with rural of Name & Adaress of Corresponding Author

Dr. Aamir Rashid Senior Resident

Department of cardiology SKIMS.

6.7% and urban of 8.37% prevalence was higher in males, 7.80% than in females 6.63%."! CAD tends to occur at a younger age in Indians, with more extensive angiographic involvement.! Various genetic, metabolic, conventional and nonconventional risk factors are responsible for

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Shauna et al; Clinical Profile of Acute Coronary Syndiomes

this.©71 With advanced therapeutic strategies, the mortality related to ACS has significantly reduced in the developed world over the past 20 years.! But the mortality remains high among Indians.!!*!?) There are very few studies describing the ACS profile in Kashmiri population . The objective of this study was to analyzed the clinical, angiographic profile and risk factors in acute coronary syndrome (ACS) patients of North Indian population.

Aims and Objectives To study the clinical profile, risk factors,

angiographic profile and short-term mortality of

acute coronary syndrome patients in our population. MATERIALS AND METHODS

The study was conducted in the Postgraduate Department of Medicine at S.M.H.S_ Hospital, Srinagar. It was prospective; Observational study. It included patients of either sex admitted in medicine department in between the period from April 2014 to August 2015 with diagnosis of acute coronary Syndromes which include STEMI, NSTEMI and Unstable Angina. Detailed history, physical examination and relevant investigations were done. All cause 30 day mortality was studied in all patient taken under study.

RESULTS

In our study total of 693 ACS patients were enrolled. The mean age of patients was 60.724 12.02 years range (32-90 years).Males were 522 while as females were 171(M:F 4:1).The _ baseline characteristics and risk factor profile is shown in [Table 1]. 308(44%) were diabetics while as 385(56%) were non-diabetics. Hypertension was present in 516 of 693 patients (74.45%). BMI > 25 was seen in 405 (58.44%) patients and 45 patients (6.5%) had BMI of more than 30.Smoking as a risk factor was present in 456 patients (65.80%). Past history of CAD was present in 87 (12.5%) of patients .Dyslipidemia was present in 415 (59.8%) patients. The clinical presentation and Killip class is shown in [Table 2]. The distribution of coronary vessel involvement in various types of ACS is shown in [Table 3] with SVD being most common while as the patterns of specific coronary involvement showed LAD most commonly affected as shown in [Table 4]. Complications; ventricular septal rupture occurred in 1 (0.1%), free wall rupture in 1 (0.1%), cardiogenic shock in 20 (2.8%), severe mitral regurgitation in 2 (0.28%), complete heart block in 5 (0.7%) patients. Total 50 (7.2%) patients died in hospital. Diabetics had more mortality than non diabetics (10 % vs 6% p<0.05).

Table 1: Baseline parameters

Parameters Baseline Values Age ( Years) 60.72+ 12.02 Male n( %) 522(75.32%) Risk factors n (%)

Diabetes 308(44) Smoking 456(65.8) Hypertension 516(74.45) BMI> 25 405(58.44) Family history 60(8.6%) Dyslipidemia 415(59.8)

Hb 13.142.1 Ejection fraction( median %)

STEMI 50 UA/NSTEMI 58

Table 2. Clinical presentation

Symptoms Number Of Patients (%)

Chest pain 637(91.9)

Breathlessness 486(70)

Sweating 520 (75)

Palpitation 346 (49.9)

Giddiness 263 (37.9)

Vomiting 103 (14.8)

Abdominal pain 50(5.7)

Killip Class 1 423 (61)

Killip Class 2 184 (26.5)

Killip Class 3 60 (8.6)

Killip Class 4 26 (3.8)

Table 3: Distribution of coronary vessels involvement

in ACS patients.

Acs | Nor Non- Svd N | Dvd Tvd Lm mal Signif | (%) N(%) | N(%) | N N icant (%) (%) | N(%)

UA 41. 3(8.3 15(41.6 | 10(27. 3(8.3 1(2.

(36) | 11%) | %) 6) 771%) | %) 7%)

NST | 522.2 | 1044 | 14061. | 47@0. | 2206 | 3d.

EMI | %) %) 67%) | 7%) %) 3%)

(227)

STE 20(4. 34(7.9 | 237(55. | 86(20 49(11. | 400.

MI 65%) | %) 11%) %) 39%) 9%)

(430)

Table 4: Pattern of coronary artery involvement

ACS Number LA

LCXx RCA N | LM n

(%) DN | N(%) | (%) (%) (%) UA 36(5.19%) 10 11(30.5) | 1(2.7% 23 (| 27.7) ) 63.8) NSTE | 2272.7% | 159 3(1.3% MI ) (70) | 76(33. | 63(27.7) | ) 4) STEMI | 430(62.04 | 305 138 4(0.9% %) (70.9 | (32) 16438. | ) ) 1)

> AS © > s

60 50 40 30 7 i ; x0 | ih ans 10 al @ NSTEMI 0 aa Th cy Rs °°

@ STEMI

Figure 1: Distribution of coronary vessels involvement

in ACS patients.

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DISCUSSION

This is one of the few studies describing ACS profile in Kashmiri population. The mean age of presentation of our patients was 60.724 12.02 years range (32-90 years). This is in difference to other Indian ACS registries which have more earlier age of presentation, however it is similar to some western studies.!!7!9?41 Males predominated (M:F 4:10), this can be attributed to the gender bias and atypical __ presentation, also. observed in INTERHEART study (South Asian cohort overall male, 76% and South Asian cohort, 85%).?7! We also noticed higher proportion of STEMI cases among ACS which is consistent with CREATE registry. The prevalence of hypertension in our ACS patients was 75% .This is higher as compared with INTERHEART study (31%). 44% were diabetics It is higher as compared to INTERHEART , however near to other Indian \studies.!”'°! By 2025, the number of diabetics in India is projected to surpass

57.2 million. Diabetics have endothelial dysfunction, dyslipidemia, chronic inflammatory state which is responsible for increased atherosclerosis. Smoking was present as risk factor in 65% of the cohort. Smoking was also most common modifiable risk factor in INTERHEART.BMI more than 30 was seen in 6.5 % of patients which is less as compared with INTERHEART (44%), which may be due to different criteria used in INTERHEART( waist hip ratio).Dyslipidemia was present in 60% of the cohort, however no significant relationship could be found between levels of various lipid parameters and CAD severity on angiography. Single-vessel disease was most prevalent across all ACS group followed by double-vessel and triple vessel which is similar to other studies.?374] Unstable angina was more commonly associated with normal coronaries (11.1%) compared to NSTEMI (2.2%) and STEMI (4.6%). Many patients especially females who are diagnosed as UA are actually false positive cases, which account for higher number of normal coronaries in this group. Angiographically the absolutely normal vessels in STEMI can be attributed to complete recanalization whether postthrombolysis or spontaneous. In our study, prevalence of multi-vessel disease (double vessel disease and triple vessel disease) was almost double in diabetic, newly detected diabetes (63.8%, 51%) as compared to normal glycemic status group in which double vessel disease plus triple vessel disease is 31.7% Diabetic status had a significant impact on morbidity & mortality of the patients with ACS in our study. Patients with diabetes and first time detected diabetes had more number of patients in advanced Killip class (Killip class 3 -32.3% and 20.6% resp.) compared to patients with normal blood sugar (8.6%). In our study all cause 30 days mortality in known diabetics was 10.8% and those of first time detected diabetics was 8.8% which is

10.

11.

12.

13.

14.

15.

almost double of the normal glycemic acute coronary syndrome patients [5.8%].

CONCLUSION

STEMI was most common presentation. LAD was most commonly involved vessel .Males predominated in our ACS population. Hypertension and Smoking were most prevalent risk factors. Diabetics had more aggressive disease with higher morbidity and mortality as compared to non- diabetics.

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How to cite this article: Sharma S, Rashid A, Ashraf M, Ismail M, Tanvir M, Sharma P, Ajaz S. Clinical Profile of Acute Coronary Syndromes (ACS) in North Indian Population: A Prospective Tertiary Care Based Hospital

Study. Ann. Int. Med. Den. Res. 2017; 3(5):ME50-ME53.

Source of Support: Nil, Conflict of Interest: None declared

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